Physician Documentation Tips
Lisa Werner, MBA, MS, CCC-SLP
Director of Consulting Services
Documentation
Why is documentation so important to medical necessity?
 This is a time of “defensive documentation”
• Just like universal precautions – assume any and all charts will
be audited.
 A reviewer of your medical record will only see the ink and
paper you send.
 In some cases they are incentivised to deny your claims!
Documentation
What is your perception of these statements from actual medical
records?
 The patient has no previous history of suicides.
 The patient refused autopsy.
 Discharge status: alive but without my permission.
 She stated that she had been constipated most of her life
until 1989 when she got a divorce.
 Rectal examination revealed a normal-size thyroid.
 On the second day the knee was better, and on the third day
it had completely disappeared.
 The patient has been depressed since she began seeing me
in 1993.
 Healthy appearing decrepit 69 year old male, mentally alert
but forgetful.
Documentation
When auditors review our charts, all they see is what we have
documented. They don’t know the patient and don’t know our
protocols for patient care.
Physician Documentation
Purpose:
 Establish medical necessity
 Clearly state why the patient needed to occupy an inpatient
rehabilitation bed
 Indicate why the patient requires an intense level of
rehabilitation services
 List problems and services that are needed
 Define why patient could not have their needs met in a
skilled nursing facility
AND
 Document information required to ensure continuity of high
quality care
Physician Documentation
Physician By-In for Medical Necessity
 Physicians should be partnered with for the good of the
patient and facility so that they:
• Understand the importance of medical necessity and medical
necessity documentation in rehab
• Can identify how medical necessity can be assimilated into their
current documentation style
Physician Documentation
What’s so special about Physical Medicine and Rehabilitation?
 Combining into one Plan of Care
• Medical treatments
• Therapy treatments
Physician Documentation
What’s so special about Physician documentation?
 CMS stated that if they could identify that the stay was
reasonable and necessary through the pre-admission
screening and the post-admission evaluation, they would
spend less time reviewing the rest of the chart.
The Rule
Documentation Requirements
 Contractors must consider the documentation in the IRF
record when determining if admission was reasonable and
necessary, focusing on:
• pre-admission screening
• post-admission physician evaluation
• overall plan of care
• admission orders
The Rule
Requirements for the Pre-admission Screening
 CMS believes that a comprehensive pre-admission screening
process is the key factor in initially identifying appropriate
candidates for IRF care.
 Pre-admission screening is an evaluation of the patient’s
condition and need for rehabilitation therapy and medical
treatment.
• It is required documentation of the clinical evaluation process
that forms the basis of the admission decision.
• Serves as the primary documentation by the IRF clinical staff of
the patient’s status prior to admission and of the specific
reasons that led the IRF clinical staff to conclude that the IRF
admission would be reasonable and necessary.
• Must be detailed and comprehensive.
The Rule
Preadmission screening should show:
 That the patient has the appropriate therapy needs for
placement in an IRF
• The patient is expected to make measurable improvement that
will be of practical value in terms of improving the patient’s
functional capacity or adaptation to impairments.
 That the patient’s condition is sufficiently stable to allow the
patient to actively participate in an intensive rehabilitation
program
• The patient is able and willing to participate in an intensive
rehabilitation program that is provided through a coordinated
interdisciplinary team approach in an inpatient setting.
The Rule
Pre-admission screening should show:
 An interdisciplinary team approach to care requires that
treating clinicians interact with each other and the patient to
define a set of coordinated goals for the IRF stay and work
together in a cooperative manner to deliver the services
necessary to achieve these goals.
 That the patient requires the intensive services of an
inpatient rehabilitation setting:
• The patient “generally requires and is reasonably expected to
actively participate in at least 3 hours of therapy per day at least
5 days per week and is expected to make measurable
improvement that will be of practical value to improve their
functional capacity or adaptation to impairments.”
The Rule
Scope of pre-admission assessment should include:
 Patient’s prior level of function (prior to the event or condition that
led to the patient’s need for intensive rehabilitation therapy)
 Expected level of improvement
 Expected length of time needed to reach that level of improvement
 Evaluation of the patient’s risk for clinical complications
 Conditions that caused the need for rehabilitation
 Combination of treatments needed (one of which must be PT or OT)
 Expected frequency and duration of treatment in the IRF
 Anticipated discharge destination
 Any anticipated post-discharge treatments
 Other information relevant to the care needs of the patient
The Rule
Pre-admission screening timeline, approval and retention:
 Individual elements of the pre-admission screening may be
evaluated by any clinician designated by a rehab physician,
as long as the clinicians are licensed or certified and qualified
to perform the evaluation within their scopes of practice and
training.
 Each IRF may determine its own process for collecting and
compiling the pre-admission screening information. The
focus of the review of the screening will be on its
completeness, accuracy and the extent to which it supports
the appropriateness of the admission decision.
The Rule
Pre-admission screening timeline, approval and retention:
 Must be completed within the 48 hours immediately
preceding the IRF admission.
 If the patient is not admitted within 48 hours of the
screening, an update conducted in person or by telephone no
more than 48 hours prior to admission is required to
document changes in the patient's medical and/or functional
status.
 Rehabilitation physician must review and document his or her
concurrence with the findings and results of the preadmission screening prior to the IRF admission.
The Rule
Pre-admission screening timeline, approval and retention:
 IRF is responsible for developing a thorough pre-admission
screening process for patients admitted to the IRF from the
home or community-based environment which includes all
the required elements described.
 Pre-admission screens cannot be done over the telephone;
however, updates can be done over the telephone. Preadmission screenings can be done from faxed patient
records.
 Must be retained in the patient’s record.
The Rule
Requirement for a Post-Admission Physician Evaluation
 To be completed by a rehabilitation physician within 24 hours
of admission to
• Document the patient’s status on admission to the IRF
• Compare it to that noted in the pre-admission screening
documentation
• Begin development of the patient’s expected course of treatment
that will be completed with input from all of the interdisciplinary
team members in the overall plan of care
• Identify any relevant changes that may have occurred since the
pre-admission screening
• Provide guidance as to whether or not it is safe to initiate the
patient’s therapy program
• Support the medical necessity of the IRF admission
• Include a documented history and physical exam, as well as a
review of the patient’s prior and current medical and functional
conditions and comorbidities
The Rule
Requirement for a Post-Admission Physician Evaluation
 It would be useful for the post-admission physician
evaluation to:
• Describe the clinical rehabilitation complications for which the
patient is at risk and the specific plan to avoid them
• Describe the adverse medical conditions that might be created
due to the patient’s comorbidities and the rigors of the intensive
rehabilitation program, and the methods that might be used to
avoid them
• Predict the functional goals to be achieved within the medical
limitations of the patient
The Rule
Requirement for a Post-Admission Physician Evaluation
 Serves as a combination medical/functional resource for all
team members in the care of the patient as they prepare to
contribute to the overall plan of care
 Requires the unique training and experience of the
rehabilitation physician, as he or she performs a hands-on
evaluation of the patient
 Does not require the physician to obtain input from the
interdisciplinary team prior to completing, although it would
be in the best interest of the patient if team member input
were provided
 The document must be retained in the medical record
The Rule
Requirement for a Post-Admission Physician Evaluation
 The conclusion of a post-admission evaluation may result in a
change from the pre-admission conclusion that the patient is
appropriate for IRF care – in such cases, appropriate action
should be taken.
• The rehabilitation physician must note the discrepancy and
document any deviations from the pre-admission screening
• For example, patient believed to be able to tolerate 3 hours per
day, but only tolerates 2 hours on day one due to pain from the
ambulance trip to the IRF. In this case the reason for the
temporary change must be noted in the patient’s medical record
– no need to discharge
Physician Documentation
Admission Post Admission Assessment Format
• Medical Necessity – “The etiologic diagnosis and comorbidities
listed below require the 24 hour availability and frequent
intervention of a physician with specialized training in
rehabilitation.”
List of cormorbidities & interventions
Describe the clinical rehabilitation complications for which the
patient is at risk and the specific plan to avoid them
Describe the adverse medical conditions that might be created due
to the patient’s comorbidities and the rigors of the intensive
rehabilitation program, and the methods that might be used to avoid
them
Physician Documentation
Admission Post Admission Assessment Format (continued)
• Rehab Necessity (Medical Impact on Function) –
Treatment plan:
Include nursing (“24 hr. rehab RN for bowel program, therapy
carryover, pt edu., skin, . . .”)
Include therapy (“Intensive therapy for 3 hours/day 5
days/week. Interventions: PT to address . . . OT to address . .
. , etc” OR “Refer to complete admission orders for
interventions”)
Include weekly team conferences to coordinate plan of care.
• Rehabilitation Goals:
• Prognosis:
• Estimated LOS:
• Planned Discharge Disposition:
Physician Documentation
Documentation about therapy treatment status, goals and plan in the
same document as the medical treatment plan
 Example
• We will initiate comprehensive rehabilitation program with
physical therapy, occupational therapy, recreational therapy, 24
hour rehabilitation nursing and physicians. She will benefit from
this comprehensive rehabilitation program to address ADLs and
mobility status post surgery as she is currently requiring
moderate assistance for ADLS and mobility
• Hypertension – will monitor and adjust dosing of Norvasc and
hydrochlorothiazide due to recent uncontrolled pressures
• Postop anemia. Hemoglobin has been stable at 9, will continue
to monitor and consider adding iron supplementation if this
continues to be an issue. Will hold off for now as patient has
constipation and iron can be constipating
• Rehabilitation therapies. Goals to manage pain, increase
ambulation and ADLs to goal of independent level and to work
on range of motion with CPM machine. Assess for equipment
needs and home safety
Physician Documentation
Links medical and therapy issues so it is clear how they interrelate.
 Example
• A 72-year old female, previously modified independent,
following cerebellar infarct now has decreased balance and
coordination. She is now unable to return to prior level of
function. Needs inpatient rehab, physical, occupational and
speech therapies for decreased function and cognition. Rehab
physician management is needed therapy plan of care,
management of pain control with non-narcotic use, management
of chest pain and monitoring for complications following stroke.
Rehab nursing to work on bowel and bladder training, transfers,
education.
• Physical therapy to work towards improvement of bed mobility,
transfer training, balance/coordination with gait to a modified
independent level
• Rehab nursing to support therapy goals, return to modified
independent with bowel/bladder, educate on prevention of stroke
• Occupational therapy . . .Speech therapy . . .
Discussion
•
•
•
•
What are you finding difficult with the PAA?
What items are you using as potential complications or risks?
How do you address function?
How do you divide the responsibility for completing the
H&P/PAA with the PA or FNP?
The Rule
Requirement for Evaluating the Appropriateness of an IRF
Admission / Inpatient Rehabilitation Facility Medical Necessity
Criteria
 Must reasonably be expected to actively participate in, and
benefit significantly from, the intensive rehab therapy
program.
• This occurs when the patient’s condition and functional status
are such that:
The patient can reasonably be expected to make measurable
improvement (that will be of practical value to improve the patient’s
functional capacity or adaptation to impairments) as a result of the
rehabilitation treatment and
such improvement can be expected to be made within a prescribed
period of time.
The Rule
Requirement for Evaluating the Appropriateness of an IRF
Admission / Inpatient Rehabilitation Facility Medical Necessity
Criteria
 The patient requires physician supervision by a rehabilitation
physician (defined as a licensed physician with specialized
training and experience in inpatient rehabilitation).
• The information in the patient’s IRF medical record must
document a reasonable expectation that at the time of
admission to the IRF, the patient’s medical management and
rehabilitation needs require an inpatient stay and close physician
involvement.
• Means that the rehab physician must conduct face-to-face visits
with the patient at least 3 days per week throughout the
patient’s stay in the IRF to
Assess the patient both medically and functionally (with an emphasis
on the important interactions between the patient’s medical and
functional goals and progress), as well as
Modify the course of treatment as needed to maximize the patient’s
capacity to benefit from the rehabilitation process.
The Rule
Requirement for Evaluating the Appropriateness of an IRF
Admission / Inpatient Rehabilitation Facility Medical Necessity
Criteria
• Candidates for IRF admission should be assessed to ascertain
the presence of risk factors requiring a level of physician
supervision similar to the physician involvement generally
expected in an acute inpatient environment, as compared with
other settings of care (proposed rule).
• Per CMS, during the past 25 years, it was often assumed that
“close medical supervision” was demonstrated by frequent
changes in orders due to a patient’s fluctuating medical status.
Currently, however, patients’ medical conditions can be more
effectively managed so that they are less likely to fluctuate and
interfere with the rigorous program of therapies provided in an
IRF.
• All IRFs may increase the frequency of the physician visits as
they believe best serves their patient populations.
Physician Documentation –
Progress Notes
Proving medical necessity during the stay
 Close medical supervision means patient requires medical
care daily
 Evidenced through physician visits and progress notes
• Do each of these visits demonstrate active intervention by the
physicians on the medical and rehabilitation needs of the
patient?
• Are there changes in orders for the rehabilitation intervention?
Physician Documentation –
Progress Note
Daily Progress Note
 Subjective:
 Objective:
• Vitals: BP , T , P , R , Pulse ox
• LUNGS: clear to auscultation bilaterally, rhonchi, rales, wheezes,
crackles
• CV: regular rate and rhythm, murmurs, rubs, gallops
• Abd: soft, non-tender, normal active bowel sounds, obese
• Ext: cyanosis, clubbing, edema, calf tenderness (right and left)
• Neuro:
• Labs:
 Plan:
• Medical issues being followed closely
• Issues that 24 hours rehabilitation nursing is following
• Rehab progress since last note
• Justification for continued stay
• Continue current care and rehab or adjustment to plan of care
Physician Documentation –
Progress Note
Saying it:
 Document progress with rehabilitation programs
 Document changes in plan of care
 Document barriers to attaining goals
 Document collaborative efforts of team and other consulting
physicians
Physician Documentation –
Progress Note
Remember to include
 Medication changes – document why changed
 Lab results – document decisions made based on lab results
 Ordering additional tests/labs – document reason why
ordered, discuss risks, advantages, hasten rehab
participation and discharge
 Document interaction with other professionals
 Document patient’s functional gains as discussed with patient
Physician Documentation –
Progress Note
Documentation about therapy treatment status, goals and plan in the
same document as the medical treatment plan
 Example
• Therapy progress is delayed due to new onset cognitive issues, I
will order a speech therapy consult
• Pain is limiting progress in all disciplines so we will increase the
patient’s pain medications to include . . .
• Missed 1 hour of therapy due to nausea and vomiting, will add
Phenergan PRN for reoccurrence
Physician Documentation –
Progress Note
Links medical and therapy issues so it is clear how the two are
interrelated
 Example
• Hypertension remains uncontrolled despite adjustment in
Norvasc. This has resulted in fatigue and discomfort that have
caused the patient progress slowly with PT and OT. Will consult
cardiology to assist with control of hypertension and remove this
barrier to intensive therapy participation.
• Missed 1 hour of therapy due to nausea and vomiting per PT, will
add Phenergan PRN for reoccurrence and monitor participation
in intensive rehab via conversations with therapy.
Discussion
• How do you access information to comment on the patient’s
functional status or progress?
• Are there statements that you like to include regarding
function?
• How do you share responsibility for the progress notes with the
PA and FNP?
• How do you indicate your participation in the extender’s visits?
The Rule
Requirement for an Individualized Overall Plan of Care
 Essential to providing high-quality care in IRFs since
comprehensive planning of the patient’s course of treatment
early on leads to a more coordinated delivery of services to
the patient. Such coordinated care is a critical aspect of the
care provided in IRFs.
 Requires that an individualized overall plan of care be
developed for each IRF admission by a rehabilitation
physician with input from the interdisciplinary team by the
end of the fourth day following the patient’s admission to the
IRF.
 Must support the determination that the IRF admission is
reasonable and necessary.
 Must be maintained in the medical record.
The Rule
Requirement for an Individualized Overall Plan of Care
 Synthesized by a rehabilitation physician from:
• Pre-admission screening
• Post-admission physician evaluation
• Information garnered from the assessments of all therapy
disciplines
• Information from the assessments of other pertinent clinicians
The Rule
Requirement for an Individualized Overall Plan of Care
 Purpose is to support a documented overall plan of care. The
overall plan of care must detail:
• Estimated length of stay
• Patient’s medical prognosis
• Anticipated functional outcomes
• Anticipated discharge destination from the IRF
• Anticipated interventions that support the medical necessity of
the admission
Based on patient’s impairments, functional status, complicating
conditions, and any other contributing factors. Should include these
details about the PT, OT, SLP, P/O therapies expected:
o Intensity (# of hours/day)
o Frequency (# of days/week)
o Duration (total # of days during IRF stay)
The Rule
Requirement for an Individualized Overall Plan of Care
 Individual clinicians will contribute, but it is the sole
responsibility of a rehabilitation physician to integrate the
information that is required in the overall plan of care and to
document it in the patient’s medical record.
 If the overall plan of care differs from the actual length of
stay and/or expected intensity, frequency and duration, then
the reasons for the discrepancies must be documented in
detail in the patient’s medical record.
 Good practice to conduct the first interdisciplinary team
meeting within 4 days of admission to develop the overall
individualized plan of care. It is the IRF’s choice to develop
the internal process.
Discussion
• How do you keep up with when the overall plan of care is due?
• Is someone checking behind you to ensure that the document is
completed in a timely manner?
• Do you use a template for the document?
• Does your electronic record pull the pieces together for you?
Could it?
Questions?
Lisa Werner, MBA, MS, CCC-SLP
Lwerner@erehabdata.com
202-588-1766